As Cuba readies around 650 medics to earthquake-ravaged parts of Ecuador, a new book explores Cuba's history of medical internationalism.

When the Ebola virus began to spread through western Africa in the fall of 2014, much of the world panicked. Soon, over 20,000 people were infected, more than 8,000 had died, and worries mounted that the death toll could reach into the hundreds of thousands. The United States provided military support; other countries promised money. Cuba was the first nation to respond with what was most needed: it sent 103 nurses and 62 doctors as volunteers to Sierra Leone. With 4,000 medical staff (including 2,400 doctors) already in Africa, Cuba was prepared for the crisis before it began: there had already been nearly two dozen Cuban medical personnel in Sierra Leone. After an initial assessment, Cuba dispatched another 296 to Guinea and Liberia. Since many governments did not know how to respond to Ebola, Cuba trained volunteers from other nations at Havana’s Pedro Kourí Institute of Tropical Medicine. In total, Cuba taught 13,000 Africans, 66,000 Latin Americans, and 620 Caribbeans how to treat Ebola without being infected. It was the first time that many had heard of Cuba’s emergency response teams.

The Ebola experience is one of many covered in John Kirk’s new book "Health Care without Borders: Understanding Cuban Medical Internationalism." It has a very different focus than his "Cuban Medical Internationalism: Origins, Evolution and Goals," co-authored with Michael Erisman in 2009. That book was a definitive work on the political history of Cuba’s medical involvement across the globe. Health Care without Borders provides updates on the recent expansion of Cuba’s programs, with a focus on the politics of international medical cooperation.
What to do when no one likes you
Cuba’s most persistent difficulty in developing international medical policy has been the intense hostility it faces from some other countries’ medical associations and governments, including those in the U.S. As a psychologist, I use the term “neglect projection” to encompass several of these attacks on Cuban humanitarianism. The term “projection” describes individuals who attribute their own unacceptable thoughts or impulses to another. Political projection would be a country attributing its own reprehensible action to another government. Medical neglect projection against Cuba takes a variety of forms. Medical associations in several Latin American countries have displayed intense hostility toward Cuban doctors, accusing them of taking jobs from the country’s own doctors; coming to another country just to spread propaganda; lacking qualifications; and not providing sufficient follow-up care.

The claim that jobs are being taken away from doctors in Brazil or Venezuela is belied by the fact that Cuban medical staff go to poor and rural areas where native doctors in those countries will not work. The Hugo Chavez government began the first "Barrio Adentro" (Inside the Neighborhood) program in 2003, to provide community medicine to poor and working-class Venezuelan districts. The call went out for Venezuelan doctors to participate; only fifty volunteered. It was this pathetic response that led Cuba to deploy over 9,000 of its own medical personnel by the end of that year. After Barrio Adentro began, the Venezuelan Federation of Medicine (FMV) demanded that Cuban doctors be expelled, partially because they were accused of spreading leftist propaganda. Yet unlike the ultra-politicized FMV, Cuban doctors have been trained to not participate in the politics of any country where they are serving. This is critical for medical agreements with countries that, unlike Venezuela, have a right-wing government as well as right-wing doctors.

Medical associations in Costa Rica and Chile charged that students trained to be doctors in Cuba scored lower on qualifying exams. This overlooks the unique focus in Cuban medical education on community health in distressed and rural areas, family medicine, and disaster management. Kirk reports that one question Cuban doctors often pose to their students is: “What would you do and how would you make the diagnosis if you were working in the middle of the Amazon and did not have access to any diagnostic tests?” (58). Cuban doctors aim to diagnose over 80 percent of medical problems through examinations and detailed histories. Given that the Cuban system has done far better at lowering infant mortality rates and improving other health indicators, instead of asking how students trained in Cuba perform on tests in other countries, it would be more useful to ask how graduates from Costa Rican or Chilean medical schools would perform on examinations in Cuba.

Perhaps the wildest accusation hurled at Cuban doctors has been that ophthalmologists in Barrio Adentro leave patients at risk if they are not present for postoperative complications. In fact, Cuban doctors have more staying power in distressed communities than do those making the charge. When Cuban doctors rotate home, other ophthalmologists from the island replace them.

The other major form of neglect projection has been to ignore or minimize the significance of Cuba’s emergency response teams for floods, earthquakes, hurricanes, tsunamis, volcanoes, epidemics, and the Chernobyl meltdown. These stories rarely appear in the corporate media, despite dozens of Cuban life-saving interventions. Many Americans first learned of Cuba’s disaster missions from news photographs of the 1,586 doctors waiting to leave Havana for New Orleans after Hurricane Katrina in 2005. Not only did President Bush refuse the offer; when U.S. State Department spokesman Sean McCormack thanked 50 organizations and countries for offering assistance, Cuba was noticeable by its omission.

Five years later, Haiti was not at all reluctant to accept Cuba’s help following the country’s devastating earthquake. Cuba was the key provider of help, since it had had so many medical personnel in Haiti since 1998. Over the years, 6,000 Cuban medical staff have treated over three million Haitians. Cuba also had previous emergency experience in Haiti, having sent a medical brigade during the massive flooding of 2004. Within a month of the 2010 earthquake, many foreign emergency teams were gone. But 600 Cubans and 380 Haitians trained in Cuban medical schools remained. In October 2010, Haiti was hit by the first cholera outbreak it had seen in over a century. Had Cuba not been in the habit of staying in a country after the initial excitement of disaster relief, and if it had not been teaching Haitians preventive medicine, the cholera death toll would have been much worse.

Though Cuba was in Haiti before the earthquake, provided the quickest and most professional emergency assistance, and remained long after the earthquake was history, Spain’s leading paper, El Pais, omitted Cuba from its list of countries that provided help. In the United States, a 2012 study by Harvard Medical School failed to mention Cuba’s contribution. Fox News actually criticized Cuba with the astounding claim that it failed to provide assistance. Meanwhile, the 22,000 Americans in Haiti were almost entirely military. Not only did U.S. doctors reach Haiti later and depart sooner than those from Cuba; they did not stay where Haitian victims huddled. After working hours, they tended to return to luxury hotels, while Cuban doctors lived in the communities of the Haitians they treated.

Disaster Tourism
Kirk uses the term “disaster tourism” to describe the way that many rich countries respond to medical crises in poor countries. Many go to disaster areas, he writes, “to have an ‘experience’ rather than provide meaningful assistance to those affected” (118). Many end up getting in the way of serious rescue work. The approach of Cuban doctors is in stark contrast to disaster tourism. Cubans have extensive training in intercultural disaster response. They build on the experience of thousands of medical staff who have already worked in poor countries. Cuban response teams or replacement staff stay in afflicted countries for months or years, helping to develop programs of community medicine and preventive health.

In many ways, Venezuela is a prototype of Cuban intervention. It began with Cuban assistance during the flooding of 1999, the year following Hugo Chávez’s election as president. The first medical cooperation agreement was signed in 2000, amid widespread opposition by the Venezuelan right. The hostility greatly diminished as Venezuela’s rate of infant mortality per 1,000 live births dropped from twenty-five in 1990 to thirteen in 2010. Huge numbers of Venezuelans have received treatment from Cuban or Cuban-trained doctors. Indeed, the greatest change in recent years has been Venezuela’s taking over much of the care and training formerly provided by and in Cuba.

"Operacion Milagro" (Operation Miracle), well-known for restoring sight to over three million people, began in Venezuela by accident. In 2004, Venezuela and Cuba were partnering in a program to teach literacy to eight million people when they realized that a major reason that many could not read was poor vision. Patients from Venezuela and throughout Latin America began flooding into Havana for eye surgery. The second stage of the program saw Cuba training Venezuelan and Bolivian doctors to perform eye surgery for their own and neighboring countries. Operacion Milagro has been widely acclaimed for achieving such a great impact on so many lives at such a small cost. Much of the blindness in Latin America is preventable, often caused by living conditions such as contaminated water, malnutrition, and inadequate access to health care. Being blind is vastly worse in a poor country than in a rich one: families have fewer resources to spend on blind relatives, who become a burden on the family and face a life expectancy half that of the general population.

Health Care without Borders ties the issue of blindness into the first great investigation of its kind regarding disabilities. The family burden factor is why the handicapped ordiscapacitados are often referred to as minusvalidos (those of lesser value). Meeting the needs of disabled people might seem routine in the United States, but it is highly unusual in impoverished countries. Many millions of poor Latin Americans were amazed to find Cubans working with their government to address their needs. Some had to be reached by helicopter, donkey, or canoe. In Bolivia, 101 surveyed communities were so remote that they did not appear on any map. By 2013, hundreds of thousands of those surveyed in Cuba, Venezuela, Ecuador, Nicaragua, Bolivia, and Saint Vincent and the Grenadines had received concrete support such as wheelchairs, walkers, hearing aids, and prosthetic limbs.

Though most of what Kirk addresses are new twists on recognizable themes of Cuba’s medical internationalism, he also brings to light areas likely unfamiliar to many readers, including Chernobyl and the South Pacific. The April 26, 1986, meltdown at Chernobyl occurred only a few years prior to the collapse of the Soviet Union, forcing Cuba to pay a high price for its humanitarianism. Cuba opened its doors, hospital beds, and a summer camp to 25,000 Ukrainians, mostly children. Many had severe injuries or chronic pathologies. Some stayed in Cuban hospitals for months or years. In October 2011, Ukrainian President Viktor Yanukovych expressed his gratitude and promised to pay the full cost of treatment. Ukraine never got around to paying Cuba. The cost of medicine alone was estimated at US$350 million.

The island nations of the South Pacific offer Cuba no strategic advantage, virtually no trade, and no investment opportunities. Yet Cuba has sent hundreds of medical staff to the region, which in turn has sent hundreds of its students to train as doctors in Havana. Cuba helped set up a small medical school in Timor-Leste, which is now training doctors for other Pacific island nations. The fact that half of Cuban doctors are women has been very important in Java, where Muslim women are highly reluctant to be examined by a man.

Medical technology
Kirk’s story of Cuba’s research on medical biotechnology is the chapter that most intrigues me (though it may distress many others). As a resident of St. Louis, a veritable plantation of Monsanto, I have participated in and organized dozens of demonstrations at the company’s world headquarters, as well as forums and conferences. It is necessary to compare the use of biotechnology by global corporations with that of Cuba to decide if they are basically the same or fundamentally different.

Technologies have various effects when introduced. Some, such as antibiotics, are positive, even if their ultimate goal is corporate profit. Others undermine organized labor: a classic example is the new molding machine adopted by the Chicago McCormick manufacturing plant in the mid-1880s. It could be run by unskilled workers, who promptly replaced the skilled workers of the National Union of Iron Molders. Still other technologies destroy small competitors so that large companies can better control the market. No case is clearer than the use of genetically modified organisms (GMOs) in agriculture. By use of market control (i.e., making non-GMO seeds unavailable), terror (such as lawsuits against resistant farmers), and the pesticide addiction treadmill, GMO giants such as Monsanto increase the cost of food production. This destroys the livelihood of small farmers across the globe while transforming the large farmers who remain into semi-vassals of these multinational lords of seeds and pesticides.

In using new technologies to attack labor or gain market control, capital is willing to create inferior products. McCormick used molding machines that produced inferior castings that cost consumers more, because they were an invaluable weapon against the union. Likewise, GMOs in agriculture result in lower-quality food. Since two-thirds of GMOs are designed to create plants that can tolerate poisonous pesticides such as Roundup, pesticide residues increase with GMO usage. GMOs are also used to increase the corn syrup which sweetens a growing quantity of processed foods, thereby contributing to the obesity crisis. At the same time, uniform food engineered to survive transportation and have a longer shelf life contains less nutritional value. Use of GMOs in corporate agriculture is one of the largest contributing factors to the phenomenon of people being simultaneously overweight and undernourished.

How do these disastrous effects of new technologies in corporate agriculture compare with Cuba’s use of biotechnologies in medicine? Kirk convincingly argues that Cuba has produced new medicines that improve people’s lives while sharing its biotechnology knowledge with other countries, in ways that empower rather than subdue them. Even a partial list of drugs developed in Cuban laboratories is impressive. Use of Heberprot B to treat diabetes has reduced amputations by 80 percent. Cuba is the only country to create an effective vaccine against type-B bacterial meningitis, and it developed the first synthetic vaccine for Haemophilus influenza type B (Hib), which causes almost half of flu infections. Cuba has also produced the vaccine Racotumomab against advanced lung cancer, and has begun clinical tests for Itolizumab to fight severe psoriasis.

Patents for these and the vast number of other medical innovations are held by the Cuban government. There is no impetus to increase profits by charging outrageously high prices for new drugs, so these medications become available to Cubans at a much lower cost than they would in a market-based health care system like that of the United States. This has a profound impact on Cuban medical internationalism. The country can provide drugs, including vaccines, at a cost low enough to make humanitarian campaigns abroad more doable. Use of synthetic vaccines for meningitis and pneumonia has resulted in the immunization of millions of Latin American children.

Cuba’s second phase of medical biotechnology is also unknown in the corporate world. This is the transfer of new technology to poor countries, so that they can produce drugs themselves. Collaboration with Brazil has meant meningitis vaccines at a cost of 95 cents rather than $15 to $20 per dose. Cuba and Brazil are working together on several other biotechnology projects, including Interferon alpha 2b, for hepatitis C, and recombinant human erythropoletin (rHuEPO), for anemia caused by chronic kidney problems.

Kirk’s discussion of agricultural biotechnology is limited to anti-pest poisons such as BioRat, sent by Cuba to Peru to fight an outbreak of bubonic plague by killing rats. BioRat is supposedly safe because it breaks down. However, Monsanto also claims that Roundup poses no threat because it “breaks down,” but the resulting chemicals are highly toxic. The history of pesticides and psychotropic drugs that are claimed to be “safe,” or to have only minimal side effects, and are then found to have severe consequences, is a long and tortuous one. Let us just say that the jury is still out on Cuba’s use of toxins (including those developed with biotechnology) to control pests.

No country, even one whose medical policies have saved millions of lives, should get a pass on a potentially negative practice. Every new social and technological change should be open to scrutiny and comradely criticism. Cuba has certainly made errors that could damage public health. Its gravest mistake, one that was more serious than all others combined, was the decision during the 1980s to build a nuclear power plant. That project was thwarted by the 1989–90 collapse of the Soviet Union and a consequent loss of funding, but if the plant had gone up, it would not have been healthy, to say the least, for children and other living things on the island to risk a Chernobyl or a Fukushima. Another regrettable policy is Cuba’s almost 1950s approach to marijuana. Since it is one of the cheapest weeds to grow and could have a large variety of medical uses, Cuba is missing out on an opportunity to contribute to multiple low-cost treatments.

While we should not ignore these problematic decisions made by Cuba, they are vastly outweighed by the nation’s contributions to global health. Health Care without Borders thoroughly documents how they extend beyond specific interventions to encompass the transfer of technology and the design of new health systems. How different this is from what is happening to drug costs in the corporate world. For example, Rodelis Corporation obtained the rights to Cycloserine, one of the few antibiotics available to combat drug-resistant tuberculosis and raised its price by 2,000 percent, so that a full treatment now costs US$500,000.

In October 2015, it came to light that the Trans-Pacific Partnership (TPP) would extend the length of patent protection for pharmaceuticals to twelve years. During that time, cheaper generic alternatives to brand-name drugs could not be sold, leaving thousands, perhaps millions, of people in the twelve TPP countries unable to afford critical medications. Such trade deals reveal drug companies as having the warmth and compassion of a school of leering sharks about to begin a feeding frenzy. The path that Cuba is forging leads in the opposite direction from that demanded by production for profit.